How can sleep apnea be caused by mental health conditions?

By Dr. Deborah Miller, PhD, HSPP

Psychologist and Owner

Veteran Disability Services - vetnexusletter.com

Many veterans are unfairly denied service connection for their sleep apnea. This is often due to a lack of evidence that their sleep apnea began during service. Most veterans report that they either didn't know their symptoms of snoring and sleep trouble during service were actually sleep apnea and so never sought treatment. Or they felt as though complaining about health conditions such as sleep apnea was not consistent with military culture. Regardless, there are other paths to service-connection for sleep apnea that are not direct.

Many veterans are service-connected for mental health conditions that began or were caused by events that happened while in service, including PTSD, anxiety, and depression. It is less commonly known that the VA may grant service connection for obstructive sleep apnea (OSA) caused by service-connected mental health conditions such as PTSD, anxiety, and depression. Many people don't even know that OSA can be caused by mental health conditions at all, but the research evidence is strong to support such a connection in several ways.

• First, we know that mental health conditions often decrease a person's ability to engage in healthy behaviors such as exercise and healthy eating. People with PTSD, anxiety, and depression often experience low motivation and eat for comfort or stress relief. This leads to weight gain and obesity, which is one of the strongest risk factors for developing OSA. If you have experienced weight gain and obesity due to mental health conditions, and developed sleep apnea as a consequence of obesity, then you could likely make a credible claim that your OSA is caused by your service-connected mental health condition.

• Second, mental health conditions often cause poor coping habits such as increased use of alcohol or smoking cigarettes as a way to self-medicate. Alcohol use and smoking are two more risk factors for developing OSA. An expert in OSA conditions would know this and be able to write a strong nexus letter that reflects how your service-connected mental health conditions led to increased alcohol or cigarette use, which in turn led to the development of OSA.

• Finally, there is increasing scientific evidence that disorders like PTSD and anxiety are directly responsible for the development of OSA through biological pathways. For instance, anxiety and PTSD both cause "hyperarousal" - meaning, a low physical threshold for the body to have a stress response to external stimuli. Hyperarousal can result in sleep disturbances and sleep-disordered breathing conditions such as OSA. Additionally, the chronic release of stress hormones caused by hyperarousal in anxiety and PTSD conditions is known to cause upper airway dysfunction that can lead to sleep apnea.

If you're considering submitting a claim for OSA secondary to a service-connected mental health condition, it is advisable to speak with someone who is familiar with such cases so that you can make sure you've got your evidence in order before submitting. There are helpful free services that may be available to you, such as DAV (Disabled American Veterans). A large number of disability claims are approved WITHOUT needing to pay for extra evidence such as independent exams or nexus letters.

While at lower levels of review, it can feel like a coin toss as to whether the VA will grant service-connection for sleep apnea secondary to mental health conditions, at the higher levels of review such as the Veteran Board of Appeals (VBA), it is common for them to approve such cases, especially if the veteran's claim is accompanied by a high-quality nexus letter (medical opinion) from an independent source. A high quality nexus letter will include a careful review of your personal records, research evidence such as that provided above (and more), and a sound rationale as to why the clinician believes your sleep apnea is caused by your mental health condition. In fact, the VA often states that "the value of a nexus letter is found in its reasoning" - meaning, the letter cannot just give an opinion, but it has to support that opinion with logic and evidence.

Unfortunately, many VA C&P examiners rely on brief exams, an incomplete review of your records, and a lack of knowledge about the research on OSA secondary to mental health. They often provide the VA with incomplete and incompetent medical opinions, yet the VA often relies on those same opinions when initially denying your case. However, at higher levels, it is clear that a well-formed nexus letter can make all the difference in these cases.

You can even directly read decisions by the VBA from their archives granting service connection for sleep apnea caused by service-connected mental health conditions to see what evidence they used to make their decisions - in most cases you will find that the veteran has secured a medical opinion with research evidence and a logical rationale supporting their opinion. You can also see what happens when a veteran does NOT have a high-quality medical opinion and/or nexus letter to support their claim - this is an example of a case from the Veteran Board of Appeals archives where the veteran obtained a nexus letter that contained factual inaccuracies and no logical rationale to support the medical opinion, and the VBA denied the veteran's claim of OSA secondary to PTSD for lack of quality evidence in his favor. You'll find that the VBA typically relies on medical opinions (such as nexus letters) from doctors and mental health professionals that provide a sound rationale and rely on research evidence to support their opinions.

If you're in need of a high quality nexus letter to support your claim for obstructive sleep apnea secondary to a service-connected mental health condition, Veteran Disability Services specializes in these types of letters. We rely on licensed psychologists with years of experience working on VA disability claims, who have done extensive research on the connection between OSA and mental health. Our letters are detailed and personalized, relying on evidence from your personal medical records and extensive support from scientific research to back up our opinions. Our letters are never cut-and-paste - they are always tailored specifically to your claim. Contact us today so we can begin to review your records to see how we can write you a strong nexus letter for your claim of OSA secondary to your service-connected mental health condition.